Medical Record For Little, Lawrence


Lawrence
DOB:
05/09/1940
MRN:
991788
Weight:
180lb
Admitting Diagnosis:
Ascites
Admitting Physician:
Wilson James, MD

Past Medical History

Allergies

Latex

Medical Problems

Cirrhosis

Surgical History

Paracentesis

Labs

Basic Metabolic Panel

Lab Result Tested Value Normal Value Range
Glucose 50 70-100
BUN 21 5-20
Creatinine 1.6 0.5-1.5
Sodium 141 135-145
Potassium 3.1 3.5-5.0
Chloride 102 95-105
Calcium 9.9 9-11

Complete Blood Count with Diff

Lab Result Tested Value Normal Value Range
WBC 10.1 4.8-10.8
RBC 5.2 4.7-6.1
HGB 12.8 12.6-17.4
HCT 38 37-51
MCV 82 80-94
MCH 29 27-31
MCHC 35 33-37
Platelets 110 130-400
Segmented Neutrophils % 56 50-70
Neutrophils, bands 0 0-5
Lymphocytes % 27 20-40
Monocytes % 6 0-15
Eosinophils % 2 0-6
Basophils % 1 0-2
Reticulocytes 0 0-1

Coagulation Studies

Lab Result Tested Value Normal Value Range
PT 12.4 7.6-10.6
PTT 44 26-38
D-Dimer <0.50 <0.50

Liver Function Tests

Lab Result Tested Value Normal Value Range
AST 90 5-40
ALT 99 7-56
Ammonia 60 15-45
Bilirubin 5.2 0.1-1.2
Albumin 2.2 3.4-5.4

Vital Signs

Time 2000 0000 0400
Heart Rate 104 110 108
Blood Pressure 105/75 99/78 100/71
Respiratory Rate 30 28 29
Pulse Ox 96% on 2L NC 98% on 2L NC 97% on 2L NC
Temperature 98.6 Oral NOT RECORDED NOT RECORDED

Provider Notes

Time Provider Notes
2000 Wilson James, MD 80 yo male presenting to the ED with shortness of breath x a few days. Pt reports increasing fluid accumulation in abdomen over the past week. Petichiae noted to patient BLE and chest. Pt reports several episodes of vomiting blood over the past week and dark tarry stools. Pt with diminished lung sounds bilaterally, abdomen firm and distended. Plan for paracentesis. Pt also with GCS=14, confused to place and time. Asterixis noted.